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INTRODUCTION

This chapter is written by experts in the surgical treatment of a wide variety of benign esophagogastric diseases, and presents a comprehensive picture of a how to manage these patients. In this commentary, we discuss indications for operation, the surgical skill required, and the techniques required to address these benign conditions.

WHAT’S SO BENIGN ABOUT BENIGN ESOPHAGEAL DISEASES?

There is a funny thing about digestive diseases, at least when it comes to their surgical treatment (perhaps their medical treatment as well—another subject….): that is that, in the universal scales of the gods of health, there seems to be an equal “disease burden” between benign and functional diseases and cancer. This balance extends from anal/rectal disease (rectal cancer vs sphincter dysfunction, condylomata, hemorrhoids, etc), colon (colon cancer vs inflammatory bowel disease [IBD], irritable bowel syndrome [IBS], constipation, volvulus etc), small bowel (cancer vs IBD, bleeding small bowel obstruction [SBO]), Hepato-pancreato-biliary (HPB) (bilio/duodenal/pancreatic cancer vs ulcer, pancreatitis, etc.), gastric (gastric cancer vs gastroparesis, peptic ulcer disease [PUD], dyspepsia, bleeding, etc.) and esophageal (cancer vs motility disorders, achalasia, gastroesophageal reflux disease [GERD], hiatal hernia, non-cardiac chest pain, dysphagia, etc.). Obviously gastrointestinal (GI) cancer is not a good thing, and rightfully deserves a lot of attention. However, GI cancers are relatively rare when compared to functional and benign diseases. Furthermore, benign functional digestive diseases have been shown to often have a quality of life impact comparable to the worst chronic medical conditions such as diabetes, but also to debilitating acute problems such as trauma and cancer.1–4 With IBD as a possible exception, the medical world, industry, and the public spends more time, money, and human resources on GI cancers than it does on the far more prevalent, costly, and often equally debilitating chronic/functional benign conditions. Of course, digestive cancers kill the majority of patients, and other than from narcotic drug overdose, the benign diseases seldom lead to death.

IS SURGERY THE BEST OPTION FOR PATIENTS WITH BENIGN OR FUNCTIONAL FOREGUT DISEASE?

All of the conditions addressed in this section have a surgical option. It may be a radical surgery, minimally invasive, or endoscopic, but at some point some of these benign and essentially medical problems will need some sort of surgery. This is a daunting decision point: “…at some point, some of these, and some sort of surgery…” should give any sensible surgeon pause. For the surgeon and the patient with a benign foregut issue, particularly for the more chronic or functional diagnoses, the proper answer to these questions is essential. In general, a conservative initial approach is a good idea for most conditions. For the more functional conditions—noncardiac chest pain, dysphagia, gastroparetic symptoms, etc.—extensive attempts to treat conservatively is mandatory before proceeding to surgery. This is because there is a substantial risk that surgery will not improve the patient’s symptoms—and can even make them worse. For benign disease with a ...

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